How to Build a Culture of Good Health: Gabor Maté

Physical well-being depends on more than keeping our bodies fit. Emotions and the people who come into our lives matter just as much.

“I never get angry,” says a character in one of Woody Allen’s movies. “I grow a tumor instead.” Much more scientific truth is captured in that droll remark than many doctors would recognize. Mainstream medical practice largely ignores the role of emotions in the physiological functioning of the human organism. Yet the scientific evidence abundantly shows that people’s lifetime emotional experiences profoundly influence health and illness. And, since emotional patterns are a response to the psychological and social environment, disease in an individual always tells us about the multigenerational family of origin and the broader culture in which that person’s life unfolds.

We human beings are biopsychosocial creatures whose health or illness reflects our relationship with the world we inhabit—including all the variables of family, class, gender, race, political status, and the physical ecology of which we are a part. A recent article from the National Institutes of Health called for a new foundational theory for medicine, based on a “biopsychosocial-ecological paradigm.” Given the ideological limitations of mainstream medicine, this forward-looking initiative is not likely to be heeded soon.

As early as the second century, the Roman physician Galen noted the connection between emotional burden and illness, an observation repeated by many other clinicians over the centuries. The pathway from stressful emotions, often unconscious, to physical disease was often driven home to me as a family physician and palliative care practitioner, although nothing in my medical education even remotely hinted at such links. People I saw with chronic disease of all kinds—from malignancies or autoimmune conditions such as rheumatoid arthritis or ulcerative colitis to persistent skin conditions such as eczema and psoriasis, and neurological disorders like Lou Gehrig’s Disease (ALS), multiple sclerosis, Parkinson’s, and even dementia—were characterized by certain unmistakable emotional life patterns. Among these was the chronic repression of so-called negative emotions, especially of healthy anger, as in the Woody Allen character’s wry confession; an overriding sense of duty, role, and responsibility; an undue concern for the emotional needs of others while ignoring one’s own; and, finally, a core belief—again, often unconscious—that one is responsible for how other people feel and that one must never disappoint others. The expression “the good die young” has—sadly—more validity than we sometimes appreciate.

Exemplifying the characteristic of an overwrought sense of duty, role, and responsibility, New York Times contributor Julia Baird recently reported her diagnosis with ovarian cancer. “I have always been healthy and strong,” she wrote in a recent column. “I regularly do hot yoga and swim a two-kilometer stretch in a bay teeming with fish near my home in Sydney, all while caring for my two little kids, hosting a TV show, writing columns and making the final edits on the book I am writing.” Inadvertently, Baird depicts precisely the “I can do anything, I’ll be everything to everybody” multitasking persona I found in everyone I ever met with her particular malignancy. People are unaware, and their physicians rarely know to inform them, that such self-imposed stress is a major risk factor for disease of all kinds.

But is it purely self-imposed? It is not accurate to see it that way. A materialistic culture teaches its members that their value depends on what they produce, achieve, or consume rather than on their human beingness. Many of us believe that we must continually prove and justify our worthiness, that we must keep having and doing to justify our existence.

Lou Gehrig, the baseball great after whom ALS is named, embodied self-abnegation to the nth degree, as do all people with ALS I have ever treated, interviewed, or read about—or have been described in medical papers. His famous record of consecutive games played was not about his indestructibility, but about his unwillingness to surrender his self-identity as invulnerable, with no needs. He suffered injuries like all other athletes: All his fingers had been broken at least once; some more often. He would play even when wincing with pain and sick to the stomach with the agony of it, but his dutifulness would not allow him to rest.

Gehrig’s story, as those of many people with chronic illness, leaves us with the question of how such emotional patterns help potentiate physical illness. Why do people develop and maintain such self-harming traits?

Compulsive self-disregard and emotional repression are never deliberate or conscious—nobody can be faulted for them. They begin in early childhood as coping mechanisms. Gehrig, for example, had an alcoholic father and a highly stressed mother. As a child, he assumed the shell of invulnerability because the responsibility thrust upon him was that of being the emotional caregiver to his parents. Such role reversal, said psychiatrist John Bowlby, the pioneer of attachment research and theory, is inevitably a source of pathology for the child later on. Gehrig was compelled in his childhood to develop a persona that, in time, became his ineluctable self-identity. This is how he adapted to his dysfunctional environment; he knew himself no other way.

“Short-term physiologic and psychological adjustments that are necessary for immediate survival and adaptation … may come at a significant cost to long-term outcomes in learning, behavior, health, and longevity.”

The separation of mind and body is an erroneous view, incompatible with science.

During our dependent and vulnerable childhoods we develop the psychological, behavioral, and emotional composite that later we mistake for ourselves. This composite, which we call the personality, often masks a real person with real needs and desires. The personality is not a fault—in stressed environments it evolves primarily as a defense, a defense that can turn saboteur.

The separation of mind and body is an erroneous view, incompatible with science. Personality traits—that is, psychological patterns—conduce to disease because the brain circuits and systems that process emotions not only exert a profound influence on our autonomic nerves, as well as our cardiovascular, hormonal, and immune systems: In reality, they are all conjoined. The recent, but no longer new, discipline of psychoneuroimmunology has delineated the many neurological and biochemical mechanisms that unite all these seemingly disparate systems into one super-system.

A somewhat breathless report in Science Daily outlined the latest such finding, from the University of Virginia:

“In a stunning discovery that overturns decades of textbook teaching, researchers have determined that the brain is directly connected to the immune system by vessels previously thought not to exist. The discovery could have profound implications for diseases from autism to Alzheimer’s to multiple sclerosis.”

In effect, when we repress emotions—just as when we are completely at their mercy, such as in moments of untrammeled rage—we are playing havoc with our nervous system, hormonal apparatus, immune system, intestines, heart, and other organs. The result can be chronic or acute illness. As repressed anger eventually turns against us, the immune system can as well, as in autoimmune disorders, for example.

Interactions between the brain and body also determine that adverse early childhood circumstances—even in utero experiences—leave us in the long term with more than psychological and emotional effects. The physical impact of early childhood experiences can also directly promote disease. Studies from the United States and New Zealand have shown, for example, that healthy adults who suffered childhood mistreatment were more likely to have elevated inflammatory products in their circulation in response to stressful experiences. Such overactive stress reactions are, in turn, a risk factor for conditions such as heart disease, diabetes, and a host of other illnesses.

It is impossible to overstate the impact of childhood trauma on adult mental and physical health. Myriad studies have demonstrated that early-life suffering potentiates many illnesses, from mental diseases such as depression, psychosis, or addiction to autoimmune conditions to cancer. One Canadian study demonstrated that childhood abuse raised the risk of cancer nearly 50 percent, even when controlled for lifestyle habits such as smoking and drinking.

The first question is never why the addiction, but why the pain?

Addictions in particular are responses to early trauma. Whether to drugs, food, gambling, or whatever other form they take, all are attempts to soothe stress and emotional pain. The first question is never why the addiction, but why the pain? We cannot understand the addictions that beset our society without recognizing the suffering and stress they are intended to alleviate, or the childhood trauma at their source. In this light, the obesity epidemic now facing us reflects primarily an epidemic of pain and stress.

Astonishing to say, most medical students never hear the word “trauma” in all their years of training, except in the the sense of physical injury. “The medical profession is traumaphobic,” a well-known colleague in San Francisco once told me. The results for patient care are devastating, whether in the treatment of physical or psychiatric conditions—a distinction that, given the mind/body unity, is in itself misleading.

Individual family dynamics unfold in the context of culture and society. Just as families have their histories in which they transmit trauma across the generations, so do societies. We can see, then, why the poor and the racially oppressed and the historically traumatized are more prone to disease. Need we mention the high rates of alcoholism, violence, obesity, diabetes, and overdose deaths amongst aboriginal populations in North America and, say, Australia, or the relatively unfavorable health outlook and life expectancy of black Americans?

The effects of trauma become multigenerational through repeated psychological dysfunctions. The new science of epigenetics is identifying the mechanisms that even affect gene functioning. The children of Holocaust survivors, for example, have altered genetic mechanisms leading to abnormal stress hormone levels. Animal studies are showing that the physiological effects of trauma can be passed on even to the third generation.

Finally, family stresses, trauma, and social and economic deprivation can also affect human brain development in ways that lead to behavioral problems, learning disabilities, and mental illness. CT scan studies at the University of Wisconsin showed that brain centers responsible for academic performance were up to 10 percent smaller in children who grew up in the poorest homes. Why? Because the human brain itself is a social organ, shaped in its neurophysiological and neurochemical development by the child’s relationships. In the words of the above-cited Pediatrics article:

“The interaction of genes and experiences literally shapes the circuitry of the developing brain, and is critically influenced by the mutual responsiveness of adult-child relationships, particularly in the early childhood years.”

Parents stressed by multigenerational trauma, relationship issues, economic insecurity, maternal depression, or social disconnection are simply unable to give their children the “mutually responsive” attuned interactions that optimal childhood development requires. The result is the epidemic of developmental disorders among our children that we are now witnessing. In line with the prevailing ideology, the medical response is mostly pharmaceutical. Rather than considering the environment that, throughout childhood, shapes the brain, we seek to manipulate the child’s brain chemistry instead.

To be whole is much more than to experience the absence of disease.

What then are people to do when doctors, the gatekeepers to health care and its primary providers, are blind to the basic realities of what generates health and what undermines it? When their training denies them knowledge of the unshakeable unity of mind and body, of emotions and physiology? When they do not recognize that social factors are far more powerful determinants of health than genetic predispositions? When they are unaware of the powerful role of psychological trauma in human life?

On the societal level, we must understand that health is not an individual outcome, but arises from social cohesion, community ties, and mutual support. In this alienated culture, where “friends” may be virtual electronic entities rather than human beings, too many suffer from what University of Chicago psychologist John Cacioppo calls “the lethality of loneliness.” We need a broad attitudinal and practical shift, consciously willed and created, toward a culture based on the fundamental sociality of human beings. We know all too well, from data too persuasive and too somber to be disputed, that emotional isolation kills.

Policymakers and community leaders need to be taught that economic and social disparities, insecurities, and stresses, as well as racial or ethnic inequalities, inevitably result in health problems and vastly increased health costs. In truth, almost all diseases are social diseases.

Health promotion must begin at conception. In the womb the growing human is already affected by maternal stress. Pregnant women need much more than blood tests, physical exams, and ultrasounds. They require emotional support so the hormones of stress do not chronically flow into the fetus via the umbilical cord. Current birthing practices, egregiously over-medicalized, interfere with natural physiologic processes and maternal-infant bonding.

With the role of parental presence and attunement being recognized in brain and personality development, young mothers and fathers must be helped to spend much more time with their children. In advanced European countries even fathers are accorded parental leave.

Adults need to know, even if their physicians often do not, that their health issues are rarely isolated manifestations. Any symptom, any illness is also an opportunity to consider where our lives may be out of balance, where our childhood coping patterns have become maladaptive, exacting costs on our physical well-being.

When we take on too much stress, whether at work or in our personal lives, when we are not able to say no, inevitably our bodies will say it for us. We need to be very honest with ourselves, very compassionate, but very thorough in considering how our childhood programming still runs our lives, to our detriment.

Ultimately, healing flows from within. The word itself originates from “wholeness.” To be whole is much more than to experience the absence of disease. It is the full and optimal functioning of the human organism, according to its nature-gifted possibilities. By such standards, we live in a culture that leaves us far short of health.

The importance of nutrition and a healthy ecology, of an environment free of toxins and pollution, need hardly be stressed. They, too, are social issues more than individual ones.

I’m often asked how people should approach their physicians, who may be very adept at their craft but limited by the narrowness of the medical ideology. “It’s the same as going to a bakery,” I reply. “When you enter a bakery, don’t ask for salami, just as when you go to the butcher, it is no use to ask for cookies.” Receive, I suggest, what the physician can offer—and often that can be miraculous—but do not seek what the doctor cannot. Find alternative sources for what most physicians cannot provide: a holistic approach that considers not organs and systems but the entire human organism. Take responsibility for how you live, the food you ingest, your emotional balance, your spiritual development, the integrity of your relationships.

Give yourself, as best you can, what your parents would have loved to grant you but probably could not: full-hearted attention, full-minded awareness, and compassion. Make gifting yourself with these qualities your daily practice.

“A culture can be toxic or nourishing,” writes Thom Hartmann. If we wish to take full responsibility for health in our society, we must not only be vigilant guardians of our personal well-being, we must also work to change structures, institutions, and ideologies that keep us mired in a toxic culture.

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